The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Disturbed personal identity.

Risk for injury.

Ineffective coping.

Anxiety, panic.

Answer and Explanation

The Correct Answer is B

A) Disturbed personal identity could be relevant in the context of a mental health issue, but it is not the most immediate concern given the client's current presentation. While it may be important to address over time, it does not take precedence in the acute phase.

B) Risk for injury is the most critical problem to include in the client's plan of care. The client's lack of sleep, pressured speech, and increase in sexual promiscuity indicate a potential manic episode, which can lead to impulsive and unsafe behaviors. Prioritizing the risk for injury ensures the safety of the client and others, making it essential for the immediate care plan.

C) Ineffective coping is a concern that may develop in response to the client's current symptoms. However, addressing immediate safety needs is more urgent than focusing on coping mechanisms at this point.

D) Anxiety and panic might be present, but they are not as clearly defined in the client's current symptoms as the risk for injury. The focus should remain on preventing harm and ensuring the client is safe during this acute episode.

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Correct Answer is A

Explanation

A) The statement "It is essential not to abruptly discontinue taking the medication" indicates the client’s awareness of the critical importance of tapering off benzodiazepines like alprazolam to avoid withdrawal symptoms, which can include rebound anxiety, seizures, and other complications. This demonstrates a fundamental understanding of medication safety and the potential risks associated with abrupt discontinuation.

B) Reporting any decrease in anxiety using a 10-point scale is beneficial for monitoring progress but is not as critical as understanding the implications of stopping medication suddenly. This reflects an awareness of managing anxiety but not necessarily the highest priority in self-care.

C) Attending individual and group therapy sessions is important for comprehensive treatment of GAD. However, this statement does not reflect the most immediate self-care concern related to the medication.

D) Reporting dizziness, light-headedness, or sedation shows the client’s awareness of potential side effects, which is important, but again, it does not encompass the crucial self-care goal regarding the safe management of alprazolam.

A. Wear sunscreen when going outside to prevent effects of sun sensitivity. B. Notify your healthcare provider immediately if involuntary movements develop. C. Drink water frequently throughout the day as the medication increases thirst. D. Check blood pressure daily and notify the healthcare provider if it increases

Correct Answer is B

Explanation

A) Wearing sunscreen when going outside to prevent effects of sun sensitivity is important for clients taking certain antipsychotic medications, but it is not the most critical instruction. While fluphenazine can cause photosensitivity, the risk of developing involuntary movements (extrapyramidal symptoms) is a more immediate concern that could significantly affect the client’s quality of life.

B) Notifying the healthcare provider immediately if involuntary movements develop is crucial when taking fluphenazine. This medication can lead to extrapyramidal symptoms such as tardive dyskinesia or acute dystonia, which require prompt assessment and intervention to prevent long-term complications. Educating the client about these potential side effects empowers them to seek timely help.

C) Drinking water frequently throughout the day is generally good advice for overall hydration, but fluphenazine does not significantly increase thirst. While maintaining hydration is important, the focus should be on the potential for serious side effects like involuntary movements, making this instruction secondary in priority.

D) Checking blood pressure daily and notifying the healthcare provider if it increases is relevant for some medications, particularly antihypertensives or those that can cause orthostatic hypotension. However, with fluphenazine, the more critical instruction revolves around recognizing and responding to neurological side effects rather than routine blood pressure monitoring, making this less of a priority.

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The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's understanding of the discharge teaching, which statement made by the client shows awareness of the most important self-care goal?

Correct Answer is A

Explanation

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

Correct Answer is B

Explanation

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